SELECT LANGUAGE EN ES COVID-19 Test Registration Form Your Protected Health Information is of the utmost importance. As such, all of your data is fully encrypted in accordance with HIPAA regulations and standards. Test Registration - CTTY No Scheduling 1General Info2Insurance3COVID-194Appointments5Complete HiddenTell us about yourselfFirst Name* Last Name* Email* You will receive an email with your lab results to this address. Please check for accuracy.Phone*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code What county do you live in?*Select an optionApacheCochiseCoconinoGilaGrahamGreenleeLa PazMaricopaMohaveNavajoPimaPinalSanta CruzYavapaiYumaDate of Birth* Month Day Year Gender* Male Female Are you pregnant? Yes No Maybe Ethnicity* American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiin or Other Pacific Islander White Driver's License FRONT Photo* Drop files here or Select files Max. file size: 50 MB. If using a smart mobile device, tap browse to open your camera and snap a photo. Your uploads are encrypted on Google's HIPAA compliant servers.Driver's License BACK Photo* Drop files here or Select files Max. file size: 50 MB. If using a smart mobile device, tap browse to open your camera and snap a photo. Your uploads are encrypted on Google's HIPAA compliant servers. Will you be paying by cash?* Yes No—I will provide insurance OPTIONAL: Individuals who have medical benefits will not be charged any out of pocket costs, however, the company may bill your insurance. COVID testing for those without insurance will be covered by the CARES ACT and the COP.Insurance InfoWho is your insurance provider?* What's your group number?* What's your policy number?* Insurance FRONT Photo* Drop files here or Select files Max. file size: 50 MB. If using a smart mobile device, tap browse to open your camera and snap a photo. Your uploads are encrypted on Google's HIPAA compliant servers.Insurance BACK Photo Drop files here or Select files Max. file size: 50 MB. If using a smart mobile device, tap browse to open your camera and snap a photo. Your uploads are encrypted on Google's HIPAA compliant servers. COVID-19 QuestionsWill this be your first test for COVID-19?* Yes No Are you or anyone in your household employed in the healthcare industry?* Yes No Are you or anyone in your household symptomatic as defined by the CDC?*Official CDC COVID-19 Symptoms - CLICK HERE Yes No When were symptoms first onset?* MM slash DD slash YYYY Have you or anyone in your household been hospitalized within the past 30 days?* Yes No Have you or anyone in your household been admitted into the ICU within the past 30 days?* Yes No Are you a resident in a congregate care setting?*This includes nursing homes, residential care for people with intellectual and development disabilities, psychiatric treatment facilities, group homes, board and care homes, homeless shelter, foster care or other settings. Yes No Do you have any known respiratory illnesses? If so, what? Are you ill now?* Yes No INFORMED CONSENT FOR CORONAVIRUS (COVID-19) TESTING*Please carefully read and sign the following informed consent: I authorize this COVID-19 testing unit to conduct collection and testing for COVID-19 through a nasopharyngeal swab, as ordered by an authorized medical provider or public health official. I authorize my test results to be disclosed to the county, state, or to any other governmental entity as may be required by law. I acknowledge that a positive test result is an indication that I must continue to self-isolate in an effort to avoid infecting others. I understand the testing unit is not acting as my medical provider, this does not replace treatment by my medical provider, and I assume complete and full responsibility to take appropriate action with regards to my test results. I agree I will seek medical advice, care and treatment from my medical provider if I have questions or concerns, or if my condition worsens. I understand that, as with any medical test, there is the potential for false positive or false negative test results can occur. By selecting "I Accept", I have been informed about the test purpose, procedures, possible benefits and risks, and I have received a copy of this Informed consent. I have been given the opportunity to ask questions before I sign, and I have been told that I can ask other questions at any time. I voluntarily agree to testing for COVID-19. I Accept I DO NOT Accept AGREEMENT FOR SELF-ISOLATION*The local health jurisdiction has determined that if you are under suspicion for having COVID-19 due to symptoms and testing request, that it is necessary to be placed in isolation in order to prevent the transmission of this infection. It is important for you to comply with this Isolation Agreement in order to protect the public's health. Thank you for agreeing to cooperate. By selecting "I Accept", I agree to each of the following statements. I understand that I may be infected with the virus causing COVID-19 and that I meet criteria for isolation. I agree that while I wait for my COVfD-19 test results, I will remain in self-isolation. I agree that if my COVID-19 test results are positive, I will remain isolated for 7 days from this day of testing OR until at least 72 hours after my symptoms have resolved, whichever is longer. I agree that if my COVID-19 test results are negative, I will remain isolated until at least 72 hours after my symptoms have resolved. I understand that if I am not isolated while ill, I could pose a substantial threat to the health of other persons. I agree that I will not come into contact with any other person who is not isolated or ill due to potential COVID- 19 infection. I Accept I DO NOT Accept PATIENT CONSENT*I request and authorize a CLIA certified laboratory to perform a COVID-19 test(s) on the samples provided by me. My signature or that of my witness below constitutes my acknowledgement that I have been informed by the benefits and limitations of this testing, which have been explained to my satisfaction by a qualified health professional. l hereby authorize my provider to release personal information, consistent with HIPPA, to Premier Lab Solutions to include billing, audits, and other purposes. I agree to obtain and submit a valid Advanced Beneficiary Notice (ABN) signed by the beneficiary and/or insuree for any test that is not supported by a diagnosis that meets Medicare or commercial payers limited coverage/medical necessity requirements. I Accept I DO NOT Accept